Cognitive Behavior Therapy (CBT) in the

Pediatric OCD
Joe Edwards, Psy.D.
Stephanie Eken, M.D.
David Causey, Ph.D.
Prevalence of OCD in children
OCD is considerably more common
than once thought
 1 in 200 are thought to suffer from
 3 or 4 in each elementary school have
 Up to 20 adolescents in an averagedsized high school have OCD
 7 ½ million in the US will suffer OCD
during their lifetime (15 million OCD
spectrum disorders)
Prevalence of OCD cont.
Unfortunately, only 4 of 18 children
found to have OCD were under
professional mental health care
(Flament et al., 1988), of those 18
had been identified as having OCD
OCD has been called the “hidden
epidemic” (Jenike, 1989)
Factors contributing to
underdiagnosis of OCD
Factors in OCD: secretiveness & lack of
Fear of being seen as Crazy
Factors with healthcare providers:
incorrect dx.’s, lack of familiarity with (or
unwillingness to use) proven treatments,
differentiating variants of OCD symptoms
Access to good treatment
DSM-IV criteria for OCD
OCD is
characterized by
obsessions and/or
compulsions that
cause marked
distress and
interference with
social or role
Children may
present with either
obsessions or
compulsions (most
have both)
In youth, the types
of symptoms, can
change rapidly
DSM-IV criteria for OCD
 OCD behaviors can occur in a child
without meeting criteria for OCD
 DSM-IV specified OCD symptoms
must cause distress, being timeconsuming (> than 1 hr/day) , or must
significantly interfere with school,
social activities, or important
DSM-IV criteria for OCD
 Obsessions are more than simply
excessive worries about real life
 Obsessions originate from within
the mind
 At some point in the illness, the person
recognizes that the O/C are excessive
and unreasonable
DSM-IV criteria for OCD
 Specific content obsessions are not
related to another Axis I disorder
(obsessions about food in an eating disorder or
guilty thoughts with ruminations in depression)
Common OCD symptoms in
Contamination themes
Harm to self or others
Aggressive themes
Sexual themes
Forbidden thoughts
Symmetry urges
Need to tell, ask,
 Washing or cleaning
 Repeating
 Checking
 Touching
 Counting
 Ordering/arranging
 Hoarding
 Praying
Common OCD symptoms in
 OCD symptoms frequently change over
 By the end of their adolescence
most all of the classic symptoms have
been experienced by the child
Assessment of OCD
*See Merlo et al., 2005
 Clinical Interview
 Be sure to include:
Impact on activities (which ones)
Impact on family (and family dynamics)
Accomodation behaviors (see scale)
Child’s attitude toward symptoms (egodystonic versus ego-syntonic)
Diagnostic Interviews
Anxiety Disorders Interview Schedule
(Silverman & Albano, 1996) – not high
agreement between child and parent
Schedule for Affective Disorders and
Schizophrenia for School-Age Children
(Kaufman et al., 1997)
 Children Yale-Brown Obsessive Compulsive Scale
(Scahill et al., 1997)
Clinician Rated (past week)
Assess severity of symptoms, control
Some evidence that clinician-rated is
superior to subject-rated (Stewart et al.,
Leyton Obsessional Inventory-Child
Version (Berg et al., 1988)
Includes a short form
Children’s Obsessional Compulsive
Inventory (Shafran et al., 2003)
Children’s Yale-Brown ObsessiveCompulsive Scale-Child Report and Parent
Report (Storch et al., 2004)
 CBCL Obsessive-Compulsive Scale
(Storch et al., 2005)
6 items; adequate psychometrics
 Child Obsessive Compulsive Impact Scale
(Piacentini & Jaffer, 1999)*
School activities, home/family activities, social activities
 Family Accomodation Scale (Calvacoressi et al.,
Correlation with severity and family dysfunction
What is not OCD
Developmental Factors
 Most children exhibit normal age-dependent
obsessive-compulsive behaviors (Liking things
done “just so” or insist on elaborate bedtime
rituals (Gessell, Ames, & Ilg, 1974)
 By middle childhood, these behaviors are
replaced by collecting, hobbies and focused
What OCD is not
 Individuals who display excessive worry that
does not cause severe discomfort or disrupt
daily life
 O-C PD—obsessive people who are punctual
and/orderly (but perfectionism, stinginess, or
aloofness can interfere with their life or the
quality of relationships)
Compulsive eaters, Pathological Gambling,
Promiscuous sex, or Drug abuse (these people
derive pleasure from the compulsive activity)
Comorbidity with OCD
More than one disorder is often
present (the Dx. of OCD is not
Many children become so distressed
and overwhelmed by OCD symptoms
that they develop MDD
Comorbidity with OCD
Tic disorders, anxiety disorders, LD, &
disruptive behavior disorders are not
OCD is a spectrum disorder
Disorders on the OCD spectrum include:
 trichotillomania
 body dsymorphic disorder
 Tourette Syndrome/tic disorders
Only a small number exhibit signs of OC
personality disorder
What does not cause OCD
 Overly strict toilet training
 Watching a parent or sibling carry out
OCD rituals (those without a genetic
Factors that may be
related to OCD
 Early life experiences (Rachman & Hodgson,
1980) found that excessively harsh punishment
for making mistakes may predispose individuals
to develop obsessive doubts and checking
Life stress (psychosocial distress) (Findley et al.,
2003) – stress differentiate clinical OCD from
nonclinical group
OCD is a neuropsychiatric
Neuropsychology has identified the following symptoms:
 Non-verbal skills < Verbal Reasoning skills
(which place kids at risk for dysgraphia, dyscalculia, poor written
language skills, & reduced processing speed & efficiency)
 Association with Asperger Syndrome
Also included on “list” of symptoms found in “Childhood Bipolar
OCD is a neuropsychiatric
Successful treatment utilizes
serotonin reuptake inhibitors
 The “serotonin hypothesis” (OCD)
 “Grooming behavior gone awry”
Neuroimaging studies implicate
abnormalities in circuits linking the
basal ganglia to the cortex--these
circuits have responded to both BT
and SSRIs.
OCD and medical
conditions (PANDAS, SC)
Pediatric Autoimmune Neuropsychiatric
Disorder Associated with Strep (PANDAS)
 In a subgroup of children, OCD symptoms
may develop or be exacerbated by strep
With Sydenham’s chorea (a variant of
rheumatic fever--RF)
 OC behaviors are common, OCD is more
common in RF patients when chorea is
OCD associated with PANDAS or
RF/Sydenham chorea
Group A antigens may cross react with basal
ganglia neural tissue resulting in OCD or tic
If there has been a rapid onset of OCD or Tic
symptoms, or a dramatic exacerbation of
these symptoms, following PANDA or RF, the
patient should be worked up for Group A strep
infection, since antibiotic therapies may benefit
select patients
History of Behavior TX
with OCD
Traditional behavior therapy involving
Systematic Desensitization did not
produce good results with OCD patients
In 1966, Dr. Victor Meyer (a British
psychiatrist) instructed nurses working on
a Psych. Ward to actively prevent patients
from carrying out their rituals—14/15
patients shows rapid improvement
The active ingredients for
Behavior Tx—E/RP
Exposure (E)—confronting a situation
you fear
Response Prevention (RP)—keeping
yourself from acting on the compulsions
Principles for E/RP
1. Confront the things you fear as often as
2. If you feel like you need to avoid
something don’t
3. If you feel like you have to perform a
ritual to feel better, don’t
4. Continue steps 1, 2, & 3 for as long as
Habituation comes from the Latin word
habitus, for habit (to make familiar by
frequent use or practice)
After long familiarity with a situation that
at first produces a strong emotional
reaction, our bodies learn to get used to
or ignore that situation
Setting Goals
by Lee Baer, Ph.D.
1. Work on one major goal at a time
2. Carefully choose the 1st symptom to work
on—what symptom do you have the best
chance with success with?
3. Convert symptoms to goals
4. Set realistic goals
5. Rank your Goals
6. Be aware of “Flat Earth Syndrome”
7. Set long-term goals—by the end of treatment,
“I want to be able to________”
Setting Practice Goals
1. I will expose myself to X, without doing Y
2. Put practice goals in writing
3. Ask the 80% question—”If I practiced this
goal 10 times, would I likely be successful 8?
4. Use Subjective Units of Distress (SUD) ratings
to guide practice goals
5. Strive to achieve but be forgiving
6. Notice small gains
7. Set practice goals each session
Techniques to assist E/RP
by Lee Baer, Ph.D.
1. Practice with your helper
a) discuss your goals openly with helper
b) accept encouragement for even partial
c) ask any reasonable question (not for
reassurance, and trust their opinion)
d) do not argue or get angry with your
Techniques to assist E/RP
2. You will feel anxiety if you are doing the
exposures and response prevention correctly
(but it will be less than feared)
3. Keep reminders hand (index cards)
4. Reward yourself for success
5. Visualize your long-term goals
6. Let obsessions pass through your mind (do
not try and block them—due to rebound)
Techniques to assist E/RP
7. Maintain standards in E/PR (avoid keeping
fingers crossed, saying a prayer or smoking a
cigarette to reduce anxiety during an
8. Hints for RP—break down goals into small
9. Use Audiotapes (for idiosyncratic ones) and
Videotapes to intensify exposures
10. Set aside “worry time” for obsessions
11. In working with kids, parents must be
involved—a reward system can be helpful
Treatment of OCD in children
Assessment of OCD:
Individualized diagnostic assessment:
review of OCD symptoms
r/o co-morbid disorders (depressive or
disruptive disorders, other spectrum dx.’s)
review of psychosocial factors
Treatment of OCD in children
Treatment of choice for OCD in children:
is a combined treatment (CT) approach- CBT & SSRI’s
Expert consensus treatment guidelines
for 1st line treatments
 Prepubescent children: CBT (mild or severe OCD)
 Adolescents: CBT for milder OCD;
CBT & SRI (or SRI alone) for severe OCD
Treatment of OCD in children
CBT alone
Medication alone
 CBT is a remarkably
effective & durable TX
for OCD (Dar & Greist,
 Relapse is more
common following the
discontinuance of
 March (1994) found
that improvement
persisted in 6 of 9 CT
responders following
withdrawal from
medication (CBT helps
inhibit relapse)
 While “booster”
sessions may be
necessary, those who
are successfully
treated with CBT
alone tend to stay well
Treatment of OCD in children
Clinical Interview (including a review of
developmental level, temperament, level of
adaptive functioning--current and pre-morbid)
Screening Measures (CBCL & TRF & CDI)
Assessment of OCD symptoms
If possible should be administered to both
primary caregiver and child (independently)
Should be done initially and be periodically readministered to measure progress
Treatment of OCD in children
Goals of the 1st evaluative session
Review of symptoms
Obtain history (standard)
Recommendations might include:
additional assessment (psychological or medical)
academic and/or other behavioral interventions
CBT with children
Step I: Psychoeducation
The family and patient need to have an
understanding of OCD within a
neurobehavioral model
A review of the risks and benefit of CBT
Begin to externalize OCD as the “enemy”
and treatment involves “bossing back” OCD
CBT with children
Step 2: Cognitive Training (a training
in cognitive tactics for resisting OCD)
Goals of CT include: increasing self-efficacy,
predictability, controllability, and self-attributed
likelihood of a positive outcome with Exposure
& Response Prevention
Targets for CT include: reinforcing accurate
information about OCD & TX., cognitive
resistance “bossing back OCD,” and selfadministered positive reinforcement &
CBT with children
Step 3: Mapping OCD
Before Treatment
After Treatment
Transition Zone
Transition Zone
CBT with children
Step 3: Mapping continued
10 - No Way!
Fear Thermometer
8 - Really Hard
6- I’m not sure
4 - Hard
2- I’m unease
0 - No problem
CBT with children
May also use analogies that child relates
to directly due to interests in daily life:
Cartoons, sports, hobbies, etc.
Spongebob - easier
Squigwart – medium
Mr. Crabs - hard
CBT with children
Symptom List (Stimulus Hierarchy)
Trigger Obsession Compulsion Temp 1-10
CBT with children
Step 4: Graded Exposure
& Response Prevention (E/RP)
“Exposure” occurs when children
expose themselves to the feared
object, action, or thought
“Response Prevention” is the process
of blocking rituals and/or minimizing
avoidance behaviors
CBT with children
Tips in executing E/PR
OCD is the enemy and all parties work
against it
Only the child can battle against OCD,
however, he can use his allies (therapist,
parents or friends) and newly learned
strategies (CT and E/RP) to combat OCD
CBT with children
What is the role of parents?
Parents are an important part of the CBT
treatment process
While they can’t combat OCD for their child,
they can encourage the child to “boss back”
OCD and not engage in behavior that helps
reinforce OCD symptoms.
Parents should have adequate psychoeducation
about OCD and should be involved in the child’s
Questions about the Tx of
1. How long will CBT take? Weekly, then
bimonthly, and eventually monthly over
6 months (Dr. Hurley at MGH)
 If they are very determined and motivated to
work hard
 If less motivated patient’s stay in treatment
 Most important how willing is the patient to work
on Exposure and Response Prevention?
Questions about the Tx of
2. Will CBT eliminate all OCD symptoms? No
3. Is BT is affective for children as for adults?
4. Are all types of OCD are as easy to treat as
another type? No—cleaning or contamination
types are the most straight forward to apply
5. What are the most difficult types of OCD to
treat? Compulsive slowness and mental
Other approaches
Metacognitive therapy: initial results
appear to be positive
(Simons et al., 2006)
“Family-based CBT”: positive results
(Storch et al., 2007)
Family Involvement
Family education (noted above)
Family accomodation behaviors
Impact of family – parent distress
Family dynamics
Helpful Tips
What’s “GOOD” and what’s “BAD” about
the OCD behaviors? (Compare lists)
Externalize the problem, give it a name
E.g., Mr. Worry, OC Flea, etc.
Use analogies to describe what the OCD
E.g., redial button (hang up)
Helpful Tips
Work with parents on what they do that
is: “helpful” and “not helpful”? (Moritz)
Helpful: positive self-talk, avoid overinvolvement, look for positives, etc.
Not Helpful: punishment, criticism,
blaming and shame, accommodating, etc.
A Contrast in Cases (1):
Age/Gender: 7 year old boy
Symptom onset: evident since age 2
Characterized by: moderate and chronic;
obsessions – symmetry, exactness, order, moral
Attitude toward OCD: ego-syntonic – patient
angry about therapy; tantrum at 1st appt.
Family: chronic / consistent accomodation;
occasionally refused to do as he requested,
parents each with OC tendencies
Other issues: strong willed, controlling child
A Contrast in Cases (2):
 Age/Gender: 10 year old boy
 Symptoms onset: typical, gradual onset, “last 6 months”
 Characterized by: mild-moderate; obsessions – worry
thoughts / compulsions - checking and counting
 Attitude toward OCD: ego-dystonic – wanted to exclude
parents and resolve with therapist
 Family: typical responses - some accomodation, some
frustration, some refusal to support, etc.
Dynamic with older sister
Frequent inconvenience to family
 Other issues: consider issue of excluding parents in tx.
A Contrast in Cases (3):
 Age/Gender: 13 year old girl
 Symptom onset: OC tendencies for years, dramatic
onset for about 1 month near beginning of 7th grade
 Characterized by: severe disruption; obsessions –
moral, exactness, order, contamination / compulsions –
cleaning, rituals, counting, confession, reassurance
seeking, checking
 Attitude toward OCD: ego-dystonic – patient initially
worried about being “crazy”, embarrassed
 Family: healthy, typical mixed response, strong and
positive investment by mother and others in tx.
 Other issues: patient later showed trichotillomania
Treatment Approach: Case 1
 List symptoms
 Patient willing to rate how upset he feels if he can’t do them: 0 – 3
rating scale
 Started dialogue re: distress/anger
 Focused on parents:
 Minimizing accommodation behaviors with a focus on issues child rated
as 1-2 on scale
 Discussed ways to provide alternatives to child to reduce tantrums, but
then instructed parents to expect tantrums
 Also suggested we closely monitor overall level of distress as we do this
(some children develop heightened stress with no reduction in
symptoms over time)
 Developed a plan for differential reinforcement
 Outcome: parents reporting progress with limited distress
Treatment Approach: Case 2
 List obsessions and compulsions
 Developed rating symptom: 0-10 related worry/distress
 Educated child and family about OCD; some normalizing
 Externalize the problem: Mr. Worry
 Developed E/RP plan; separate sheet for each specific
problem; some conducted in office (e.g., faucet)
 Assisted parents with family dynamics, their own coping
behaviors, consequences for “being late”
 Progress monitored by parent observation (and report)
and child self-report
 Outcome: significant reduction in checking behaviors;
some issues resolved without specific intervention
Treatment Approach: Case 3
List obsessions and compulsions
Education and normalizing: “you’re not crazy”
Developed rating symptom: 0-10 related to worry/distress
Educated child and family about OCD; OCD book
Strategies: E/RP; worry plan, “worry time”, relaxation, differential
reinforcement (planned ignoring), E/RP in office (e.g., bubble sheets,
Due to severity, distress and impact on school – med. referral
Progress monitored by parent observation (and report) and child self-report
Outcome: significant reduction in OCD; still a bit embarrassed but
developed sense of humor; some mild evidence of symptoms; no obvious
impact on daily life at this time; still some trichotillomania, “amnesia” about
some of past OC behaviors
Discussed and developed relapse prevention plan

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